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Coverage

A day in a real hospital ER has as much drama, triumph, and heartbreak as any TV show. USA Today chronicled 24 hours at the University of Virginia Medical Center in Charlottesville, VA. They asked everyone -- patients, doctors and nurses, concerned family members, housekeeping staff -- to share their experiences with the health care system, and what they think about changing it. USA Today writes,

Their experiences and observations underscore why changing the health care system has proved so hard for presidents and policymakers: the complexity of the system, the pressure from chronic diseases, the shortfall in preventive care, the high costs, the competing demands -- and the life-or-death stakes.

Everyone agrees they want to preserve the quality and technological advances of American medicine...Beyond that, though, the consensus frays.

And the interviews the reporters conducted suggested that a lot of the misinformation spread about health reform this summer had gotten through.

One of the great ironies of the health reform debate is that one of the groups that is most apprehensive about the drive to cover all Americans is the group that is already covered -- America's seniors. The AARP is gearing up its efforts to soothe their fears.

Another great irony is that the Republicans now casting themselves as the defenders of Medicare have for years pursued one version after another of radically changing the very nature of Medicare -- most recently, as Ron Brownstein in the National Journalpointed out, by voting for a House GOP budget this year that would have replaced Medicare's guarantees of coverage for the elderly and disabled with a voucher.

Here's the real story that the AARP wants to get out: All Americans age 65 and up are covered by Medicare, and that won't change under health reform.

Earlier this week we explained why the status quo in health care is neither acceptable nor sustainable. In fact, in health care, there's really no such thing as the status quo. Joe Paduda at Manage Care Matters provides further evidence in his two-part look at "your life without health reform."

But when something can no longer continue, it won't. When enough Americans lose their coverage, when cost-shifting gets to the point where those left with insurance are paying thousands in premiums to cover those without, when local taxes to pay for teachers' and police benefits get so high that folks are losing their houses, when Medicare finally goes insolvent, when hospitals are collapsing due to the cost of indigent care ... then, and only then, will the screaming hordes at Town Hall meetings decide that any health care coverage is better than none.

The LA Times this week had a well-written piece arguing that the people living in states with the most to gain from health reform passage are among its most vocal critics.

As proof, they point to Wyoming. The state, "with an economy marked by farming, ranching and small businesses, has a disproportionate number of people without medical insurance. And by that measure and others, its people are among the likely winners if Congress approves a health care overhaul." The state's senior senator, Mike Enzi is the ranking Republican on the Senate HELP committee and one of the "Gang of Six" bipartisan negotiators in the Senate Finance committee. Yet at a town hall in Gillette, a state legislator stood up and demanded that Enzi pull out of negotiations, drawing a round of applause from the audience. A few days later, Enzi was delivering the weekly GOP radio address harshly criticizing the health reform proposals in Congress. (LBJ would have had a different response...)

To elaborate on the dynamic described by the LA Times, we gathered state-level data on the uninsured, poverty, and job loss to give you an idea of which states stand to lose the most from health reform's failure. The maps are taken from the Kaiser Family Foundation's excellent resource, www.StateHealthFacts.org and were modified to include our calculations and some additional employment data from the BLS.

Age rating (varying premiums based on age), like medical underwriting (varying premiums based on health status), is one way for insurers to segment risk -- separating the healthy from the sick, making insurance cheaper for some, but inaccessible and unaffordable for many others. In some markets today, premiums can vary as much as 11:1 based on a customer's age. That means the oldest customer could pay as much as 11 times more than the youngest customer simply because of his or her age! In my view, this moves beyond actuarially fair into the immoral category.

Let us not forget one of the central goals of reform is to channel self-interest to serve the social interest. In the case of insurance markets, this means forcing insurers to compete based on price, value, and customer satisfaction, rather than avoiding the sick. Allowing insurers to charge older Americans vastly higher premiums simply because they are older is not part of this vision.

For most of us, there's a moment on the first day of school when you fear you've forgotten everything you knew just a few months ago.

A similar dynamic is playing itself out in Congress, as lawmakers return to work next week weary from town halls and leery of the coming health reform debate.

Given the growing anxiety, confusion, and partisan bickering over health reform, we thought it would be helpful to put together sort of back to basics primer reminding us why we started this in the first place.

Here's a sampling of some of the opinions and editorials we've seen over the last few days.

In a weekend when Wyoming Republican Sen. Mike Enzi, part of the so-called Gang of Six bipartisan negotiators in Senate Finance, bashed Democratic-backed health plans in the GOP's weekly radio address, The New York Times published an editorial saying that Democrats may have no choice except for a "go-it-alone" strategy:

We say this with considerable regret because a bipartisan compromise would be the surest way to achieve comprehensive reforms with broad public support. But the ideological split between the parties is too wide -- and the animosities too deep -- for that to be possible.

In recent weeks, it has become inescapably clear that Republicans are unlikely to vote for substantial reform this year. Many seem bent on scuttling President Obama's signature domestic issue no matter the cost. As Senator Jim DeMint, Republican of South Carolina, so infamously put it: "If we're able to stop Obama on this, it will be his Waterloo. It will break him."...

What a relief. An intelligent essay about health reform that isn't about the public plan, illegal aliens, abortion, Granny plug-pullers or Santa Claus. (OK, we made up the part about Santa.)

In fact, it's an intelligent essay about how all the yelling about the public plan, illegal aliens, Granny killers and abortion is distracting us from what health reform is really about -- cost and coverage.

Kaiser Family Foundation President and CEO Drew Altman reminds us that the "core concern" of the American people is cost. And that's how this debate over health reform began in the first place. Cost to individuals and families. Cost to businesses. Costs to our country.

Once the summer of town meeting discontent winds down, lawmakers return to Washington and, we hope, get back to the business of fixing health care. And the hardest part Drew maintains, is still money.

For health reform, that question may be answered in the month of August.

The latest Kaiser Health Tracking Poll shows that a slim majority (53 percent) of respondents continue to think health reform is more important than ever, while 42 percent felt we cannot afford to take on health care reform right now.

Support for reform remains strong among Democrats (71 percent) as does opposition among Republicans (67 percent). However, for the first time, support has flipped among independents, with 46 percent in favor and 49 percent opposed, compared to a margin of 54 to 42 in July.

While emotions over health reform in abstract have become more polarized, the poll shows support for specific goals and elements of reform remains relatively consistent. Song-title-based highlights (Can you name the artist/band?) after the jump:

Theresa Brown, an oncology nurse, reminds us what health reform is all about.

People who get sick, the people who love them, the diseases that kill them, and the medical bills that outlive them.

Writing "A Nurse's Vew of Health Reform" in The New York Times "Well" blog, Brown told the story of a patient in his 60s -- who ironically made his living selling insurance. He bought insurance for himself, he thought he had adequately protected himself and his family. But he didn't plan well enough. Not for a disease that kept him in the hospital for months,with an insurance policy that was really an underinsurance policy. Here are excerpts:

I could offer a tableau of stories, but instead I will tell just one. A patient we had several months ago was admitted for leukemia treatment. In his mid-60s, kind and immensely likable, he went through three different rounds of what we call "induction chemo" -- the regimen and dose designed to cure. But in trying to cure his leukemia we'd weakened his immune system to such an extent that he no longer had any reserve, and fluids and intravenous antibiotics could not save him from the infection growing in his lungs.

Here are some of the highlights from the House Tri-Committee bill, HR 3200:

Medicare will reimburse for "culturally and linguistically appropriate services" to promote access for Medicare beneficiaries with limited English proficiency. (NOTE: This is not a codeword for covering illegal immigrants, as some foes of reform have contended).

Reducing health disparities would be an explicit goal in the HHS Secretary's national priorities for quality improvement in health care.

The Secretary of HHS and the Institute of Medicine would look at how providers utilize cultural and linguistic support services, design a demonstration program to pay for these services, and study the impact on reducing health disparities.

Establish a CDC grant program for community-based prevention and wellness. Significantly, "At least 50% of these funds must be spent on implementing services whose primary purpose is to reduce health disparities."